P.O Box 15118
1-800-436-4326
325 South Belmont Street
York, Pennsylvania 17405
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Adult Volunteer
Date:
First Name:
MI:
Last Name:
Home Address:
City:
Zip Code:
Home Telephone:
Email Address:
Birthdate:
Gender:

Education:
College Years:



Degree:
Graduate Degree:
Experience:
Duration:
Brief Decription:
Long Term:
Short Term(1-3 months):
Present Occupation:
Employer:
Employer Phone:
Emergency Contact:
Relationship:
Phone Day:
Phone Evening:
Referred by:
Special Training:
Skills:
Previous Experience:
Interests and Hobbies:
Prefered volunteer assignment:


Availability. A minimum of 50 hours(completed within one year) is required.
Please include two references
Reference One:
Name:
Relationship:
Phone:
Reference Two
Name:
Relationship:
Phone:
Are there limitations on your ability to serve as a volunteer?

If yes please explain:
By submitting this form, I understand that: I certify that all statements made on this application are true, correct and complete to the best of my knowledge and made in good faith. I understand that any misinformation may be cause for termination or disqualification from the Memorial Hospital Volunteer Program. I will be expected to abide by all the rules and regulations. I understand that the Volunteer Manager of Memorial Hospital has the right to remove me from serving as a volunteer at any time.
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